Tag: Insurance

March 13, 2023

Insurance requirements for prior authorization may prompt ‘devastating’ delays | CNN

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When Paula Chestnut needed hip replacement surgery last year, a pre-operative X-ray found irregularities in her chest.

As a smoker for 40 years, Chestnut was at high risk for lung cancer. A specialist in Los Angeles recommended the 67-year-old undergo an MRI, a high-resolution image that could help spot the disease.

But her MRI appointment kept getting canceled, Chestnut’s son, Jaron Roux, told KHN. First, it was scheduled at the wrong hospital. Next, the provider wasn’t available. The ultimate roadblock she faced, Roux said, arrived when Chestnut’s health insurer deemed the MRI medically unnecessary and would not authorize the visit.

“On at least four or five occasions, she called me up, hysterical,” Roux said.

Months later, Chestnut, struggling to breathe, was rushed to the emergency room. A tumor in her chest had become so large that it was pressing against her windpipe. Doctors started a regimen of chemotherapy, but it was too late. Despite treatment, she died in the hospital within six weeks of being admitted.

Though Roux doesn’t fully blame the health insurer for his mother’s death, “it was a contributing factor,” he said. “It limited her options.”

Few things about the American health care system infuriate patients and doctors more than prior authorization, a common tool whose use by insurers has exploded in recent years.

Prior authorization, or pre-certification, was designed decades ago to prevent doctors from ordering expensive tests or procedures that are not indicated or needed, with the aim of delivering cost-effective care.

Originally focused on the costliest types of care, such as cancer treatment, insurers now commonly require prior authorization for many mundane medical encounters, including basic imaging and prescription refills. In a 2021 survey conducted by the American Medical Association, 40% of physicians said they have staffers who work exclusively on prior authorization.

So today, instead of providing a guardrail against useless, expensive treatment, pre-authorization prevents patients from getting the vital care they need, researchers and doctors say.

“The prior authorization system should be completely done away with in physicians’ offices,” said Dr. Shikha Jain, a Chicago hematologist-oncologist. “It’s really devastating, these unnecessary delays.”

In December, the federal government proposed several changes that would force health plans, including Medicaid, Medicare Advantage, and federal Affordable Care Act marketplace plans, to speed up prior authorization decisions and provide more information about the reasons for denials. Starting in 2026, it would require plans to respond to a standard prior authorization request within seven days, typically, instead of the current 14, and within 72 hours for urgent requests. The proposed rule was scheduled to be open for public comment through March 13.

Although groups like AHIP, an industry trade group formerly called America’s Health Insurance Plans, and the American Medical Association, which represents more than 250,000 physicians in the United States, have expressed support for the proposed changes, some doctors feel they don’t go far enough.

“Seven days is still way too long,” said Dr. Julie Kanter, a hematologist in Birmingham, Alabama, whose sickle cell patients can’t delay care when they arrive at the hospital showing signs of stroke. “We need to move very quickly. We have to make decisions.”

Meanwhile, some states have passed their own laws governing the process. In Oregon, for example, health insurers must respond to nonemergency prior authorization requests within two business days. In Michigan, insurers must report annual prior authorization data, including the number of requests denied and appeals received. Other states have adopted or are considering similar legislation, while in many places insurers regularly take four to six weeks for non-urgent appeals.

Waiting for health insurers to authorize care comes with consequences for patients, various studies show. It has led to delays in cancer care in Pennsylvania, meant sick children in Colorado were more likely to be hospitalized, and blocked low-income patients across the country from getting treatment for opioid addiction.

In some cases, care has been denied and never obtained. In others, prior authorization proved a potent but indirect deterrent, as few patients have the fortitude, time, or resources to navigate what can be a labyrinthine process of denials and appeals. They simply gave up, because fighting denials often requires patients to spend hours on the phone and computer to submit multiple forms.

Erin Conlisk, a social science researcher for the University of California-Riverside, estimated she spent dozens of hours last summer trying to obtain prior authorization for a 6-mile round-trip ambulance ride to get her mother to a clinic in San Diego.

Her 81-year-old mother has rheumatoid arthritis and has had trouble sitting up, walking, or standing without help after she damaged a tendon in her pelvis last year.

Conlisk thought her mom’s case was clear-cut, especially since they had successfully scheduled an ambulance transport a few weeks earlier to the same clinic. But the ambulance didn’t show on the day Conlisk was told it would. No one notified them the ride hadn’t been pre-authorized.

The time it takes to juggle a prior authorization request can also perpetuate racial disparities and disproportionately affect those with lower-paying, hourly jobs, said Dr. Kathleen McManus, a physician-scientist at the University of Virginia.

“When people ask for an example of structural racism in medicine, this is one that I give them,” McManus said. “It’s baked into the system.”

Research that McManus and her colleagues published in 2020 found that federal Affordable Care Act marketplace insurance plans in the South were 16 times more likely to require prior authorization for HIV prevention drugs than those in the Northeast. The reason for these regional disparities is unknown. But she said that because more than half the nation’s Black population lives in the South, they’d be the patients more likely to face this barrier.

Many of the denied claims are reversed if a patient appeals, according to the federal government. New data specific to Medicare Advantage plans found 82% of appeals resulted in fully or partially overturning the initial prior authorization denial, according to KFF.

It’s not just patients who are confused and frustrated by the process. Doctors said they find the system convoluted and time-consuming, and feel as if their expertise is being challenged.

“I lose hours of time that I really don’t have to argue … with someone who doesn’t even really know what I’m talking about,” said Kanter, the hematologist in Birmingham. “The people who are making these decisions are rarely in your field of medicine.”

Occasionally, she said, it’s more efficient to send patients to the emergency room than it is to negotiate with their insurance plan to pre-authorize imaging or tests. But emergency care costs both the insurer and the patient more.

“It’s a terrible system,” she said.

A KFF analysis of 2021 claims data found that 9% of all in-network denials by Affordable Care Act plans on the federal exchange, healthcare.gov, were attributed to lack of prior authorization or referrals, but some companies are more likely to deny a claim for these reasons than others. In Texas, for example, the analysis found 22% of all denials made by Blue Cross and Blue Shield of Texas and 24% of all denials made by Celtic Insurance Co. were based on lack of prior authorization.

Facing scrutiny, some insurers are revising their prior authorization policies. UnitedHealthcare has cut the number of prior authorizations in half in recent years by eliminating the need for patients to obtain permission for some diagnostic procedures, like MRIs and CT scans, said company spokesperson Heather Soules. Health insurers have also adopted artificial intelligence technology to speed up prior authorization decisions.

Meanwhile, most patients have no means of avoiding the burdensome process that has become a defining feature of American health care. But even those who have the time and energy to fight back may not get the outcome they hoped for.

When the ambulance never showed in July, Conlisk and her mother’s caregiver decided to drive the patient to the clinic in the caregiver’s car.

“She almost fell outside the office,” said Conlisk, who needed the assistance of five bystanders to move her mother safely into the clinic.

When her mother needed an ambulance for another appointment in September, Conlisk vowed to spend only one hour a day, for two weeks leading up to the clinic visit, working to get prior authorization. Her efforts were unsuccessful. Once again, her mother’s caregiver drove her to the clinic himself.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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March 3, 2023

Eli Lilly to cut insulin prices, cap costs at $35 for many people with diabetes | CNN

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CNN
— 

Eli Lilly announced Wednesday a series of price cuts that would lower the price of the most commonly used forms of its insulin 70% and said it will automatically cap out-of-pocket insulin costs at $35 for people who have private insurance and use participating pharmacies.

Lilly says it will also expand its Insulin Value Program, which caps out-of-pocket costs at $35 or less per month for people who are uninsured.

President Joe Biden heralded the announcement as “a big deal.”

“For far too long, American families have been crushed by drug costs many times higher than what people in other countries are charged for the same prescriptions. Insulin costs less than $10 to make, but Americans are sometimes forced to pay over $300 for it. It’s flat wrong,” Biden said in a statement on Wednesday.

The President also urged other pharmaceutical companies to cut insulin prices.

“Last year, I signed a law to cap insulin at $35 for seniors and I called on pharma companies to bring prices down for everyone on their own. Today, Eli Lilly did that. It’s a big deal, and it’s time for other manufacturers to follow,” Biden said.

Eli Lilly says it will cut the list price of its nonbranded insulin to $25 a vial as of May 1, making it the lowest list-priced mealtime insulin available. Its current list price is $82.41 for a vial.

Lilly will also lower the list price of Humulin and its most commonly prescribed insulin, Humalog, in the fourth quarter of 2023. The current list price of a Humalog vial is $274.70, and the new list price will be $66.40. For people with commercial insurance who use participating pharmacies, the out-of-pocket costs will now be capped at $35.

Although insulin is relatively inexpensive to manufacture, the cost has been a problem for many Americans for years. At least 16.5% of people in the US who use it report rationing it because of cost.

The average price of insulin nearly tripled between 2002 and 2013, the American Diabetes Association says. GoodRx research shows that the trend has continued, with the average retail price of insulin rising 54% between 2014 and 2019.

Demand for insulin has grown significantly as diabetes has become the fastest-growing chronic disease in the world, a 2022 study found.

In the US alone, the number of adults with diabetes has doubled over the past 20 years, and more than 37.3 million people now have it, according to the US Centers for Disease Control and Prevention. Another 96 million Americans – 38% of the population – have prediabetes, a condition in which blood sugar levels are higher than normal but not high enough for a diagnosis of type 2 diabetes. This can often lead to diabetes.

People with diabetes rely on insulin because their bodies have stopped producing enough of this hormone or aren’t using it efficiently to convert food into energy.

When a person eats, their body breaks down food, mostly into sugar. This sugar enters the bloodstream, and that signals the pancreas to release insulin, which works like a key that allows the sugar to energize cells. But if diabetes keeps sugar in the bloodstream for too long, it can lead to serious problems like kidney disease, heart problems and blindness. In 2019, diabetes was the seventh leading cause of death in the US, according to the American Diabetes Association.

This year’s Inflation Reduction Act capped insulin costs for seniors who get their health coverage through Medicare Part D at $35 a month. Congressional Democrats pushed to extend that price cap to people covered by private insurance, but Republicans stripped that measure from the bill.

The US Food and Drug Administration’s approvals of generic insulin and biosimilars – drugs similar to original versions that can be made differently or with slightly different substances – have driven down the price at least somewhat, according to GoodRx.

Some states have taken matters into their own hands. Twenty-two states and the District of Columbia have price caps ranging from $25 to $100 for insulin as well as diabetes supplies and devices – but that’s only for people covered by insurance plans regulated by those states.

“While the current healthcare system provides access to insulin for most people with diabetes, it still does not provide affordable insulin for everyone and that needs to change,” David A. Ricks, Lilly’s chair and CEO, said in a statement. “The aggressive price cuts we’re announcing today should make a real difference for Americans with diabetes. Because these price cuts will take time for the insurance and pharmacy system to implement, we are taking the additional step to immediately cap out-of-pocket costs for patients who use Lilly insulin and are not covered by the recent Medicare Part D cap.”

Lilly has been one of the biggest players in the US insulin market since it became the first company to commercialize the lifesaving drug 100 years ago. The company said that its price changes should make a difference, but more is needed to help all Americans with diabetes – 7 out of 10 don’t use the company’s insulin.

The Medicare Part D cap “should be the new standard in America,” Ricks said on CNN This Morning on Wednesday.

He called on the insurance industry, policymakers and other manufacturers to join them in making insulin more affordable.

“We call on everyone to meet us at this point and take this issue away from a disease that’s stressful and difficult to manage already – to take away the affordability challenges,” Ricks told CNN’s Don Lemon.

Other companies have cut insulin costs over the years.

In 2019, Sanofi created the Insulin Valyou Savings Program, which charged patients $99 a month for insulin, regardless of income. In 2021, Novo Nordisk created a similar program called My$99Insulin.

Also that year, Novo Nordisk collaborated with Walmart to sell private-label analog insulin at a deep discount. Walmart said its ReliOn NovoLog vials and FlexPens save customers 58% to 75% off the cash price for branded insulin.

For Eli Lilly insulin, the new price cap will automatically apply at most pharmacies with no additional action from the patient. Otherwise, a coupon will be available for patients to use at the remaining 15% of pharmacies where the electronic system does not allow for the automatic price drop, Ricks said.

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February 18, 2023

A childbirth myth is spreading on TikTok. Doctors say the truth is different | CNN

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CNN
— 

Ashley Martinez has four sons and is pregnant with the daughter she’s wanted for years.

Last month, she posted a video online imploring doctors to prioritize her life, not the life of her unborn baby, if complications arise when she is in labor and it comes down to that choice.

The San Antonio, Texas, resident is due in May and is one of a number of pregnant people who have recently posted “living will” videos on TikTok.

Martinez had an emergency C-section during her last pregnancy after her umbilical cord came out before her baby, a rare but dangerous condition known as an umbilical cord prolapse that can deprive a baby of vital blood flow and oxygen.

Martinez described her last delivery as terrifying. Eight months after the Supreme Court reversed Roe v. Wade, ending a constitutional right to abortion, she said she worries about what would happen if she faced similar challenges again.

Since the ruling in June, a number of US states have criminalized abortions, leading to some fears that doctors would prioritize the life of the unborn child during a medical emergency.

Martinez lost her mother to non-Hodgkin’s lymphoma at a young age, and the thought of her children going through a similar tragedy terrifies her.

“Having to go into another delivery where I’m going to have a C-section, it’s scary for me,” said the 29-year-old. “My fourth pregnancy was my only C-section. I’ve always thought about not being here for my kids just because of what I went through growing up without my mom.”

More than a dozen US states have banned or severely restricted access to abortions following the Supreme Court’s decision eight months ago. The abortion bans have led to legal chaos as advocates take the fight to courtrooms.

Even so, several ob/gyns told CNN that a hard choice between saving a mother and baby’s lives at childbirth, like the one outlined in the TikTok videos, is highly unlikely.

This trend on TikTok has sparked a flurry of dueling videos among pregnant women and other people. Some have posted videos telling doctors in such situations to prioritize their unborn babies first, and criticizing those who expressed a different view.

Martinez concedes that her mother, who died at 25, would likely have chosen to save her child first if she could.

“My mother, she didn’t have a choice, you know?” Martinez said. “The message that I want to send is just basically nobody is wrong or right in this situation. In both situations, it is a hard decision to pick your children over your unborn baby.”

In Texas, where Martinez lives, abortions are banned at all stages of pregnancy – unless there’s a life-threatening medical emergency.

Dr. Franziska Haydanek, an ob/gyn in Rochester, New York, who shares medical advice on TikTok, said she’s noticed many “living will” videos in recent months.

In most of the videos, a woman appears alongside a written message saying something like, “If there are complications during childbirth, save me before the baby.” Some people, including Martinez, reference their children in their decision and even show them in the video.

One was posted by Tuscany Gunter, 22, a woman whose baby is due in April. Abortion after 20 weeks of pregnancy is illegal in her home state of North Carolina, and Gunter told CNN she filmed her message in solidarity with others who said they would choose themselves first.

“I wanted to make it known where I stand and to stand up with other women who are getting bashed online for saying they would rather be saved first over their baby,” said Gunter, who lives in Fayetteville.

“As a mother to three young children, I cannot dump the emotional trauma of losing their mother on them as children and expect them to cope. While I would be crushed to lose a baby, I need to think of my other living children as well … And I know the baby that passed would be safe without ever having to experience any pain or sadness.”

Another woman, Leslie Tovar of Portland, Oregon, said that even though her state has no legal restrictions on abortion, she posted her video because she feared doctors would prioritize saving her unborn child to avoid legal ramifications in the post-Roe v. Wade era.

“I have two other kids at home who need mom. I can’t bear the thought of my two young boys ages 6 and 4 without their mom,” she said.

All three women said they’ve had these conversations with their partners, who agreed they should be saved first.

Of her husband, Tovar said, “His exact words were, ‘We could always have another baby later in life but there is never replacing the mother of my boys, I couldn’t do this without you.’”

It’s true that complications occasionally come up during a pregnancy that lead doctors to recommend delivery to save the mother’s life, medical experts said.

If this is done before a fetus is viable – under 24 weeks – the chances of the baby’s survival are low, said Dr. Elizabeth Langen, a maternal-fetal medicine physician at the University of Michigan Von Voigtlander Women’s Hospital.

Roe v. Wade’s reversal did make terminating such pregnancies more complicated, Langen and Haydanek say.

In cases involving a baby that’s not viable, it could mean that even when the baby is unlikely to survive and the mom’s health is at risk, the priority will be on saving the baby due to fear of legal ramifications, Langen said.

But both doctors say these scenarios don’t occur during the birth of a viable baby. In that instance, Roe v. Wade is “less involved,” Haydanek said.

“We do everything in our efforts to save both (mother and baby),” she said. “I can’t think of a time where the medical team has had to make a decision about who to save in a viable laboring patient. It’s just not a real scenario in modern medicine – just one we are seeing played out on TV.”

Hospitals have enough resources – obstetrics and neonatal intensive care unit teams, for example – to meet the needs of both the mother and the baby, Haydanek and Langen said.

“We’re usually doing our best to take care of both the mom and the baby. And there’s very rarely a circumstance where we will do something to harm the mom in order to have the benefit of the baby,” added Langen.

“If mom’s health is deteriorating, ultimately, she’s not going to be able to support baby’s wellbeing,” Langen said. “And so generally, what we encourage folks to do is really support mom’s health, because that’s in the best interest of both mother and baby.”

Abortion rights demonstrators hold signs outside the US Supreme Court in Washington after the court overturned Roe v. Wade in June 2022.

Both doctors said it’s important for patients to talk to their health care providers about their medical concerns and share their “living will” wishes with loved ones in case there are complications during labor that require partners to make medical decisions.

However, those decisions will not involve doctors asking your partner whose life should come first, they said.

“Before getting in a fight with your partner about who they choose to save, know that there isn’t a situation where we will ask them that,” said Haydanek, who has called the TikTok trend “horribly anxiety inducing.”

She said it’s come up so many times in recent months that she made her own TikTok video to reassure expectant parents.

“Please don’t feel like you have to make this choice,” she says in the video. “I know firsthand how much anxiety there can be in pregnancy … but it’s just not a situation that you’re gonna find yourself in.”

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February 15, 2023

Almost half of children who go to ER with mental health crisis don’t get the follow-up care they need, study finds | CNN

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Editor’s Note: If you or someone you know is struggling with suicidal thoughts or mental health matters, please call the 988 Suicide and Crisis Lifeline, or visit the hotline’s website.



CNN
— 

Every night that Dr. Jennifer Hoffmann works as an attending physician in the pediatric ER, she says, at least one child comes in with a mental or behavioral health emergency. Over the span of her career, she’s seen the number of young people needing help grow enormously.

“The most common problems that I see are children with suicidal thoughts or children with severe behavior problems, where they may be a risk of harm to themselves or others,” said Hoffmann, who works at Ann & Robert H. Lurie Children’s Hospital of Chicago. “We’re also seeing younger children, especially since the pandemic started. Children as young as 8, 9 or 10 years old are coming to the emergency department with mental health concerns.

“It’s just mind-blowing.”

The surge of children turning up in emergency departments with mental health issues was a challenge even before 2020, but rates soared during the Covid-19 pandemic, studies show.

ER staffers may be able to stabilize a child in a mental health care crisis, but research has shown that timely follow-up with a provider is key to their success long-term. Unfortunately, there just doesn’t seem to be enough of it, according to a new study co-authored by Hoffmann. Without the proper follow-up, these children too often wound up back in the ER.

For their study, published Monday in the journal Pediatrics, Hoffmann and her co-authors looked at records for more than 28,000 children ages 6 to 17 who were enrolled in Medicaid and had at least one trip to the emergency department between January 2018 and June 2019. They found that less than a third of the children had the benefit of an outpatient mental health visit within seven days of being discharged from the ER. A little more than 55% had a follow-up within 30 days.

Research has shown that follow-up with a mental health care provider lowers a person’s suicide risk, raises the chances that they will take their prescription medicine and decreases the chances that they will make repeated trips to the ER.

The new study found that without a follow-up, more than a quarter of the children had to go back to the ER for additional mental health care within six months of their initial visit.

“The emergency department is a safety net. It’s always open, but there’s limited extent to the types of mental health services we can provide in that setting,” Hoffmann said. “This really speaks to inadequate access to services that these kids need.”

This dynamic can be “devastating” for parents and emergency department staff alike, she said.

“We know what a child needs, but we’re just not able to schedule follow-up due to shortages among the mental health profession. They’re widespread across the US,” she said.

A lack of professional help is a problem for many children. Before the Covid-19 pandemic, the US Centers for Disease Control and Prevention found that 1 in 5 children had a mental health disorder, but only about 20% got care from a mental health provider.

Children’s mental health has become such a concern in the US that the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry and the Children’s Hospital Association declared a national emergency in 2021.

Hoffmann’s study found that Black children fared worse than their peers. They were 10% less likely to have timely follow-up than White children – “which is very concerning, given that there are many disparities in access to care in our mental health system,” Hoffmann said.

The study can’t pinpoint why there is this racial disparity, but Hoffmann thinks there may be a few factors at play.

Black children are more likely to live in neighborhoods that have shortages of mental health professionals. There is also limited diversity among the mental health work force. Studies show that nearly 84% of psychologists are White, as are nearly 65% of counselors and more than 60% of social workers. And Black children more often rely on school-based mental health services, studies show.

Although the number of school counselors has been increasing over the years, few schools meet the National Association of School Psychologists’ recommended ratio of one school psychologist to 500 students. The national ratio for the 2021-22 school year was 1,127 to 1, the association found.

The new study found that the children who did not have mental health help before their ER visits had the most difficulty finding timely care afterward.

Dr. Toni Gross, chief of the Emergency Department at Children’s Hospital New Orleans, said she wasn’t entirely surprised by the study findings. Her hospital’s beds for with mental health concerns are “always busy,” she said.

“I’m well aware of the fact that we need more providers for these services. We deal with it every day,” said Gross, who was not involved in the new research.

The lack of providers who can do follow-up is a real source of concern. It’s not ideal to hand a phone number to a parent and hope they can arrange care, she said. It often takes weeks or even months to get a first appointment with a child and adolescent psychiatrist.

“It leaves a lot of us feeling like we wish we could do more,” Gross said. “When you always leave asking yourself at the end of the day, ‘did I really do what I set out to do, and that is to help people,’ it’s one of our biggest frustrations, and it may be one of the biggest reasons people in my group of physicians feel burnout.”

Like many children’s hospitals, hers has an active partnership with local school health programs that can provide some mental health care.

Hoffmann said that the amount of support varies by emergency department. Lurie has 24/7 coverage by mental health workers who can do an evaluation and provide recommendations for appropriate care, but not all areas do. For example, many rural emergency rooms don’t have pediatric mental health providers and may have few resources in the community, if any.

Several US counties have no practicing child and adolescent psychiatrists. Primary care physicians can help, but some patients would benefit from more specialized care, Hoffmann said.

President Joe Biden’s administration announced in August that plans to make it easier for millions of children to get access to mental health services by allowing schools to use Medicaid dollars to hire additional school counselors and social workers. He even mentioned the issue in his State of the Union address Tuesday.

But even more will need to be done. Hoffmann hopes her study will prompt policy-makers to invest more so children can access care no matter where they live. Investing in telehealth could also bridge the gap, she said, as would increasing Medicaid reimbursement rates for mental health services and more funding to pay for people to train to work with children as a mental health professional.

In a commentary published alongside the new study, the authors say their research shows that the US “is not meeting the behavioral health needs of our young people.”

“EDs are the last stop when all else has failed, and they, too, lack the resources to support, or even discharge, these patients,” the commentary says.

It points out that research has found this lack of access as far back as 2005.

“This new analysis adds to the overwhelming evidence that there is an urgent need for a dramatic change in our pediatric mental health care system,” the commentary says. “We believe it is time for a ‘child mental health moonshot,’ and call on the field and its funders to come together to launch the next wave of bold mental health research, for the benefit of these children and their families who so desperately need our support.”

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February 13, 2023

First on CNN: HHS secretary sends letter to state governors on what’s to come when Covid-19 public health emergency ends | CNN

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CNN
— 

Plans are moving forward at the US Department of Health and Human Services to prepare for the end of the nation’s Covid-19 public health emergency declaration in May.

On Thursday, HHS Secretary Xavier Becerra sent a letter and fact sheet to state governors detailing what exactly the end of the emergency declaration will mean for jurisdictions and their residents.

“Addressing COVID-19 remains a significant public health priority for the Administration, and over the next few months, we will transition our COVID-19 policies, as well as the current flexibilities enabled by the COVID-19 emergency declarations, into improving standards of care for patients. We will work closely with partners including state, local, Tribal, and territorial agencies, industry, and advocates, to ensure an orderly transition,” Becerra wrote in a draft of the letter obtained by CNN.

“In the coming days, the Centers for Medicare & Medicaid Services (CMS) will also provide additional information, including about the waivers many states and health systems have adopted and how they will be impacted by the end of the COVID-19 PHE,” he wrote. “I will share that resource with your team when available.”

Declaring a public health emergency in the United States means that certain actions, access to funds, grants, waivers and data – among other steps – can happen more quickly in response to the crisis for the duration of the emergency. A declaration lasts 90 days – unless HHS ends it – and may be renewed.

On January 30, the White House announced its intention to end the Covid-19 national and public health emergencies on May 11, signaling that the administration considers the nation to have moved out of the emergency response phase.

Becerra had agreed to give governors a 60-day notice to prepare for the end of the emergency. Thursday’s letter was sent 90 days ahead of the emergency’s planned end.

“We are having ongoing conversations about what else we need to do in the next 90 days to ensure a smooth transition. I can tell you that every one of our agencies has been working hard on this plan,” an HHS official told CNN. “We’re going to have a series of additional materials that will go out, as well as a series of conversations over the coming days and weeks.”

The end of the public health emergency will affect some Medicare and state Medicaid flexibilities provided for the duration of the emergency. This includes waivers like the requirement for a three-day hospital stay before Medicare will cover care at a skilled nursing facility.

“We’ve been working closely with the governors on the public health emergency. This is a combination of both federal flexibilities that we allow, and the states are often the ones who are using those flexibilities,” the HHS official said.

“Just about every aspect of the pandemic response, I would say, has been in partnership with our state partners. And so, I think they have been, frankly for months now, the ones that we have been going to and the ones that we publicly committed to notifying in advance of changes to the public health emergency declaration.”

But the emergency’s end will not impact the authorizations of Covid-19 devices, including tests, vaccines and treatments that have been authorized for emergency use by the US Food and Drug Administration.

During the Covid-19 pandemic, the FDA has issued about 15 times as many emergency use authorizations as it did for all other previous public health emergencies, Commissioner Dr. Robert Califf said Wednesday in a joint hearing of the House Oversight and Investigations and Health subcommittees.

“Today, we’ve issued EUAs or provided traditional marketing authorizations to over 2,800 medical devices for Covid-19, which is 15 times more EUAs than all other previous emergencies combined,” Califf said. He added that the effects of the end of the emergency declaration will be “modest” because the “EUAs are independent of the public health emergency, so we can keep them going as long as we need to.”

The emergency is slated to end May 11. “What happens on May 12? On May 12, you can still walk into a pharmacy and get your bivalent vaccine,” Dr. Ashish Jha, the White House’s coronavirus response coordinator, wrote on Twitter last week.

He said that at some point, probably in the summer or early fall, the Biden administration will transition from federal distribution of Covid-19 vaccines and treatments to purchases through the regular health care system – but that’s not happening quite yet.

Overall, there are additional Medicaid waivers and other flexibilities that states and territories have received under the public health emergency. Some of those will be terminated. But state Medicaid programs will have to continue covering Covid-19 testing, treatments, and vaccinations without cost-sharing through September 30, 2024.

The end of the public health emergency declaration means Medicare beneficiaries will face out-of-pocket costs for over-the-counter home Covid-19 tests and treatment. However, people with Medicare will continue to have no cost for medically necessary lab-conducted Covid-19 tests ordered by their health care providers.

Covid-19 vaccinations will continue to be covered at no cost for all Medicare beneficiaries.

Those with private insurance could face charges for lab tests, even if they are ordered by a provider, according to the Kaiser Family Foundation. Vaccinations will continue to be free for those with private insurance who go to in-network providers, but going to an out-of-network providers could incur charges once federal supplies run out.

And the privately insured will not be able to get free at-home tests from pharmacies and retailers anymore unless their insurers choose to cover them.

Americans with private insurance have not been charged for monoclonal antibody treatment since they were prepaid by the federal government, though patients may be charged for the office visit or administration of the treatment, according to Kaiser. But that is not tied to the public health emergency, and the free treatments will be available until the federal supply is exhausted. The government has already run out of some of the treatments so those with private insurance may already be picking up some of the cost.

The uninsured had been able to access no-cost testing, treatments and vaccines through a different pandemic relief program. However, the federal funding ran out in the spring of 2022, making it more difficult for those without coverage to obtain free services.

Also, the “ability of health care providers to safely dispense controlled substances via telemedicine without an in-person interaction is affected; however, there will be rulemaking that will propose to extend these flexibilities,” according to the letter’s fact sheet.

One of the most meaningful pandemic enhancements for states is no longer tied to the public health emergency. Congress severed the connection in December as part of its fiscal year 2023 government funding package, which state Medicaid officials had urged lawmakers to do.

States will now be able to start processing Medicaid redeterminations and disenrolling residents who no longer qualify, starting April 1. They have 14 months to review the eligibility of their beneficiaries.

As part of a Covid-19 relief package passed in March 2020, states were barred from kicking people off Medicaid during the public health emergency in exchange for additional federal matching funds. Medicaid enrollment has skyrocketed to a record 91 million people since then.

A total of roughly 15 million people could be dropped from Medicaid when the continuous enrollment requirement ends, according to an analysis the Department of Health and Human Services released in August. About 8.2 million folks would no longer qualify, but 6.8 million people would be terminated even though they are still eligible, the department estimated.

Many who are disenrolled from Medicaid, however, could qualify for other coverage.



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February 8, 2023

Sarah Huckabee Sanders gives Republican response to Biden: Full text

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Here are the full remarks, as prepared for delivery, of Arkansas Gov. Sarah Huckabee Sanders, in the Republican response to President Joe Biden’s State of the Union address.

“Good evening. I’m Sarah Huckabee Sanders. 
 
“Being a mom to three young children taught me not to believe every story I hear. So forgive me for not believing much of anything I heard tonight from President Biden. From out-of-control inflation and violent crime to the dangerous border crisis and threat from China, Biden and the Democrats have failed you.
 
“They know it. And you know it.
 
“It’s time for a change.
 
“Tonight, let us reaffirm our commitment to a timeless American idea: that government exists not to rule the people, but to serve the people.  
 
“Democrats want to rule us with more government control, but that is not who we are. America is the greatest country the world has ever known because we are the freest country the world has ever known, with a people who are strong and resilient. 
 
“Five months ago, I was diagnosed with thyroid cancer. It was a hard time for our family, particularly for our kids – Scarlett, Huck, and George – but we kept our faith and persevered. 
 
“Thanks to exceptional doctors here in Arkansas, a successful surgery, and the grace of God, I am cancer-free. 
 
“Through it all, I couldn’t help but think about my mom. 
 
“She was 20 years old and in her first year of marriage when she was diagnosed with spinal cancer. The doctors told her she might not live. If she did live, they said she’d never walk again, and if she did walk, she’d definitely never have children. 
 
“The daughter she was told she’d never have was just sworn in as the new Governor
of Arkansas and is speaking to you tonight.
 
“Adversity and fear of the unknown can paralyze us, but faith propels us to charge boldly ahead. 
 
“We can’t stand still in the face of great challenges. You and I were put on this earth for such a time as this to charge boldly ahead.
 
“I’ll be the first to admit, President Biden and I don’t have a lot in common. 
  
“I’m for freedom. He’s for government control. 
 
“At 40, I’m the youngest governor in the country. At 80, he’s the oldest president in American history.  
 
“I’m the first woman to lead my state. He’s the first man to surrender his presidency to a woke mob that can’t even tell you what a woman is. 
 
“In the radical left’s America, Washington taxes you and lights your hard-earned money on fire, but you get crushed with high gas prices, empty grocery shelves, and our children are taught to hate one another on account of their race, but not to love one another or our great country. 
 
“Whether Joe Biden believes this madness or is simply too weak to resist it, his administration has been completely hijacked by the radical left.
 
“The dividing line in America is no longer between right or left.  
 
“The choice is between normal or crazy.  
 
“It is time for a new generation of Republican leadership.
 
“Upon taking office just a few weeks ago I signed Executive Orders to ban CRT, racism, and indoctrination in our schools, eliminate the use of the derogatory term ‘Latinx’ in our government, repealed COVID orders and said never again to authoritarian mandates and shutdowns.
 
“Americans want common sense from their leaders, but in Washington, the Biden administration is doubling down on crazy.
 
“President Biden inherited the fastest economic recovery on record. The most secure border in history. Cheap abundant, home-grown energy. Fast-rising wages. A rebuilt military. And a world that was stable and at peace. But over the last two years, Democrats destroyed it all. 
  
“Despite Democrats’ trillions in reckless spending and mountains of debt, we now have the worst border crisis in American history. 
 
“As a mom, my heart breaks for every parent who has lost a son or daughter to addiction. 100,000 Americans a year are now killed from drug overdoses, largely from fentanyl pouring in across our southern border. Yet the Biden administration refuses to secure the border and save American lives. 
 
“And after years of Democrat attacks on law enforcement and calls to ‘defund the police’, violent criminals roam free, while law-abiding families live in fear.  
 
“Beyond our border, from Afghanistan to Ukraine, from North Korea to Iran, President Biden’s weakness puts our nation and the world at risk. 
 
“And the President’s refusal to stand up to China, our most formidable adversary, is dangerous and unacceptable. 
 
“President Biden is unwilling to defend our border, defend our skies, and defend our people. He is unfit to serve as commander in chief.
 
“And while you reap the consequences of their failures, the Biden administration seems more interested in woke fantasies than the hard reality Americans face every day. Most Americans simply want to live their lives in freedom and peace, but we are under attack in a left-wing culture war we didn’t start and never wanted to fight.
 
“Every day, we are told that we must partake in their rituals, salute their flags, and worship their false idols, all while big government colludes with Big Tech to strip away the most American thing there is—your Freedom of speech.
 
“That’s not normal. It’s crazy, and it’s wrong. 
 
“Make no mistake: Republicans will not surrender this fight. We will lead with courage and do what’s right, not what’s politically correct or convenient.
 
“Republicans believe in an America where strong families thrive in safe communities. Where jobs are abundant, and paychecks are rising. Where the freedom our veterans shed their blood to defend is the birthright of every man, woman, and child. 
 
“These are the principles Republican governors are fighting for. And in Washington under the leadership of Senate Republicans and Speaker Kevin McCarthy, we will hold the Biden administration accountable.
 
“Down the street from where I sit is my alma mater, Little Rock Central High. As a student there, I will never forget watching my dad, Governor Mike Huckabee, and President Bill Clinton hold the doors open to the Little Rock Nine, doors that forty years earlier had been closed to them because they were black. Today, those children once barred from the schoolhouse are now heroes memorialized in bronze at our statehouse. 
  
“I’m proud of the progress our country has made.  And I believe giving every child access to a quality education – regardless of their race or income – is the civil rights issue of our day.
 
“Tomorrow, I will unveil an education package that will be the most far reaching, bold, conservative education reform in the country. 
  
“My plan empowers parents with real choices, improves literacy and career readiness, and helps put a good teacher in every classroom by increasing their starting salary from one of the lowest to one of the highest in the nation. 
  
“Here in Arkansas and across America, Republicans are working to end the policy of trapping kids in failing schools and sentencing them to a lifetime of poverty.  
  
“We will educate, not indoctrinate our kids, and put students on a path to success. 
 
“It’s time for a new generation to lead. This is our moment. This is our opportunity. 
 
“A new generation born in the waning decades of the last century, shaped by economic booms and stock market busts, forged by the triumph of the Cold War and the tragedy of 9/11. A generation brimming with passion and new ideas to solve age-old problems. A generation moored to our deepest values and oldest traditions, yet unafraid to challenge the present order and find a better way forward. 
 
“If we seize this moment together, America can once again be the land of the free and home of the brave.
 
“During my two and a half years at the White House, I traveled on every foreign trip with the President. 
 
“A trip I will never forget was on December 25, 2018.
 
“My husband Bryan and I had just cleaned up wrapping paper that had been shoved into every corner of our house thanks to our three kids, when I had to walk out on my own family’s Christmas, unable to tell them where I was going, because the place I’d be traveling to was so dangerous they didn’t want anybody to know that the President was going to be on the ground for even a few hours.
 
“We boarded Air Force One in total darkness—there were no lights on the plane, no lights on the runway, our phones and computers shut down and turned in. We were going completely off the grid.
 
“Nearly twelve hours later in the pitch-black of the night, we landed in the war-torn part of western Iraq. It was again a similar scene—no lights on the plane, no lights on the runway.
 
“The only light you could see was coming from about a mile away in a dining hall where hundreds of troops—who were in the fight against ISIS— had gathered, expecting to celebrate Christmas with senior military leadership from around the region.
 
“They had absolutely no idea that the President and First Lady were about to walk into that room.
 
“And when they did—it was a sight, and a scene, and a sound I hope I never forget.
 
“The room erupted. Men and women from every race, religion, and region, every political party, every demographic you can imagine started chanting in perfect unison over and over and over again, ‘USA, USA, USA.’
 
“It was a perfect picture of what makes our country great.
 
“One of the young soldiers yelled from the back, ‘Mr. President, I reenlisted in the military because of you.’ The President said, ‘and son, I am here because of you.’
 
“Shortly after, that young soldier came up to me and said, ‘Sarah, you have a tough job.’ I told him ‘What I do is nothing. You take bombs and bullets. That’s a tough job.’
 
“And in a moment that I know I’ll cherish for the rest of my life, that soldier reached up, and pulled the Brave Rifles Patch he wore on his shoulder and placed it into my hand, a sign of ultimate respect, and said, ‘Sarah, we are in this together.’ 
 
“Overwhelmed with emotion and speechless, I just hugged him, with tears in my eyes and a grateful heart for our heroes who keep us free.
 
“That young man and everyone who has served before him, all of those who serve alongside him, and the thousands we know who will be called upon to serve after him, deserve to know they have a country and community back home doing our part in the fight for freedom.
 
“America is great because we are free.
 
“But today, our freedom is under attack, and the America we love is in danger.
 
“President Biden and the Democrats have failed you.
 
“It’s time for a change.
 
“A New Generation of Republican leaders is stepping up, not to be caretakers of the status quo, but to be changemakers for the American people.
 
“We know not what the future holds, but we know who holds the future in His hands. And with God as our witness, we will show the world that America is still the place where freedom reins and liberty will never die.
 
“Thank you. God bless you. And God Bless America.”

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February 1, 2023

‘My stepmother has been less than ethical’: I suspect my stepmom removed me as beneficiary from my late father’s life-insurance policy. What can I do?

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My dad passed away in March 2019. My stepmom told me I had an inheritance from my dad.  She ceased communication with me after my dad passed away. I reached out to the Department of Financial Services website for lost life-insurance policies, and received a letter saying my dad was a participant, but had named someone other than me as a beneficiary.

My stepmother has been less than ethical at times. She previously stole money from her sister’s bank account while working for the financial institution that she now runs. Her sister did not press charges, so the matter was dropped by my dad, with whom she was having an affair. Is it possible that she changed the beneficiary, and could have forged anything on behalf of my dad?

My family also suspects she tried to cash another life-insurance policy for which I was a 51% beneficiary. She sent me a check after my dad passed saying it was a “gift,” and called me nearly two years later saying a policy had just been “found” with me as 51% beneficiary. I suspect she was the 49% beneficiary. To make matters worse, that policy was through her place of business.

Suspicious Daughter

Dear Suspicious,

Anything is possible. It sounds like you are dealing with an unknown quantity, and she should not be trusted with other people’s money. Your stepmother does not, from your account, appear to be on the up-and-up, given that she reportedly stole money from her sister’s bank account. It may be that she could not bring herself to cash a policy with you receiving 49% — hence the delay —  but given the division outlined in the policy it seems unlikely that she could have kept the entire policy for herself. An executor has a responsibility to deal with an estate in a timely manner.

It’s not unheard of for people to question an amendment that was made to a trust, insurance policy or last will and testament. Priscilla Presley, the ex-wife of Elvis Presley, the “King of Rock and Roll” who died in 1977, filed legal documents in Los Angeles Superior Court last week, disputing the validity of an amendment to a living trust overseeing the estate of her late daughter Lisa Marie Presley, who died earlier this month. The 2016 amendment removed Priscilla Presley and a former business manager as trustees, the Associated Press reported.

Among the issues cited in the legal filing: Priscilla Presley was allegedly not notified of the change as required, an absence of a witness or notarization, Priscilla Presley’s name was misspelled in a document that was allegedly signed by her late daughter, and Lisa Marie Presley’s own signature was described as atypical, the news agency also reported. Aside from questions swirling over the authenticity of an amendment, changes to wills, trusts and — in your case — insurance policies must always meet certain legal standards.

“It’s not unheard of for people to question an amendment that was made to a trust, insurance policy or last will and testament.”

“Last-minute changes in beneficiaries can be a red flag for life-insurance companies,” according to LifeInsuranceAttorney.com. “Usually, the person insured by a life-insurance policy can change their beneficiaries whenever they want, so long as the change complies with any specific requirements in the life-insurance policy. However, when the insured person is elderly, severely ill or lacking mental capacity, and the change in beneficiary happens shortly before the insured person passes away, they may have been unduly influenced by others.”

“For example, a caretaker or estranged family member may convince or influence the vulnerable insured person to add them as a beneficiary on the insured person’s life-insurance policy or to remove other beneficiaries,” the firm says. What’s more, “Life-insurance companies may also deny claims if the beneficiary made a change in the beneficiary that did not comply with the requirements of the insured person’s life-insurance policy. Some policies may require that the insured person have a certain amount of witnesses present,” it adds.

Depending on the amount of money involved, you may wish to hire an attorney to see if you have a case and/or to put your mind at rest. The statute of limitations — that is, the amount of time you have to challenge the validity of a life-insurance policy — may vary, depending on the circumstances, the state where you live and/or whether new information has come to light. “The statute of limitations, in most cases, lasts for three years. But not always,” according to the Center for Life Insurance Disputes, an insurance agency in Washington, D.C.

She stopped talking to you after your father passed away: It could be that she was shoring up what was left of his estate, and figuring out what she could take for herself. Or it may be that you did not get along, and a breakdown of communication was inevitable. Or both. Were there any changes made to your father’s policy that would raise a red flag? That much is unclear. Your stepmother may have learned her lesson when she was not prosecuted by her sister for alleged financial malfeasance.

And, then again, maybe not.

You can email The Moneyist with any financial and ethical questions related to coronavirus at [email protected]ch.com, and follow Quentin Fottrell on Twitter.

Check out the Moneyist private Facebook group, where we look for answers to life’s thorniest money issues. Readers write in to me with all sorts of dilemmas. Post your questions, tell me what you want to know more about, or weigh in on the latest Moneyist columns.

The Moneyist regrets he cannot reply to questions individually.

More from Quentin Fottrell:

My mother excluded me from her will — before she died, my sibling cashed out her annuity policy, on which I was a beneficiary. Should I sue my family?

‘I’m clean and sober’: My late father left me 25% of his estate, and my wealthy brother 75%. My brother died 10 months later. Should I ask his son for his share?

‘It’s still painful’: My wife of just one year left me, took all her belongings and won’t answer her phone. How do I protect my finances?



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December 11, 2022

Financial Face-off: Should you opt for a high-deductible health plan with lower monthly costs?

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Hello and welcome to Financial Face-off, a MarketWatch column where we help you weigh financial decisions. Our columnist will give her verdict. Tell us whether you think she’s right in the comments. And please share your suggestions for future Financial Face-off columns by emailing our columnist at [email protected] 

It’s the time of year to sign up for a new health insurance plan, either through an employer or through the government’s Health Insurance Marketplace.

The decision may feel especially fraught this year. High inflation, layoffs and a potential recession are weighing on people’s minds and finances. Americans have been tightening their budgets and may be looking for ways to save money on their health-insurance costs. One way to do that, at least in terms of upfront costs, could be to sign up for a high-deductible health plan. These plans typically have lower monthly costs (premiums), but they have higher deductibles, or, the amount of money that you have to pay out of your own pocket before the insurance kicks in to cover healthcare costs.

So is this the year to try to save some cash by signing up for a high-deductible health plan?

Why it matters

It’s no secret that healthcare is expensive in the U.S., but the language of health insurance often obscures that reality with euphemisms such as “cost-sharing,” “coinsurance,” “copay” and “deductible.” Here’s a quick translation: if you see one of those terms, just mentally replace it with a dollar sign, because it means you will be paying money.

Choosing a healthcare plan is important. Medical bills can strain a household’s finances, and healthcare debt is very common. More than half (57%) of Americans have incurred debt caused by a medical or dental expense in the last five years, according to a nationally representative survey released in June by KFF, an independent nonprofit that researches healthcare issues.

One of the survey’s more troubling findings was that even people who have health insurance fall into debt, with more than four in 10 insured adults reporting that they currently had health-related debt.

In other words, the decision about which health-insurance plan to choose can have far-reaching unintended consequences.

How much can you expect to pay for health insurance? If you get yours through your job, it depends on several factors including the size of your company and the age of its workforce. On average, workers with employer-based health insurance paid $6,106 per year toward family coverage and $1,327 for individual coverage, according to KFF. People at smaller companies typically have higher premiums and bigger deductibles.

The federal government defines a high-deductible health plan as one with a deductible of at least $1,400 for an individual and $2,800 for a family.

High-deductible health plans (HDHPs) often — but not always — come with a health savings account (HSA) where people can store money tax-free to pay for medical expenses.

“ ‘Medical debt really can be the gift that keeps on giving.’”


— Karen Pollitz, a senior fellow at KFF

HDHPs have lower premiums, but are they more affordable in the long run than traditional health plans? ValuePenguin compared HDHPs vs. traditional plans in three scenarios and found that the HDHP plan holder would end up paying more overall than the traditional plan holder if they had medical expenses of $5,000 or $10,000 in a year.

However, the HDHP holder had lower overall costs than the traditional plan holder if their medical expenses were $1,000. “But banking on such an outcome — and such low need for medical care — can be a gamble in an unpredictable world,” ValuePenguin wrote.

The verdict

If you can pay the higher monthly costs, avoid a high-deductible health plan.

My reasons

“It’s very difficult to accurately predict what your healthcare needs are going to be for the coming year. And for that reason, it’s a good idea to sign up for the most comprehensive plan option that you can afford,” said Karen Pollitz, a senior fellow at KFF. Buying the cheapest option can open you up to the possibility that something is going to happen — you’ll get hit by a car, find a lump — and then “you’re going to find out the hard way how much your plan doesn’t cover and what you’re going to owe out of pocket,” Pollitz said.

As the KFF survey found, medical debt is common even among people with health insurance, she noted. “There are lots of reasons for that, but high deductibles are one culprit,” Pollitz said.

That debt can have serious long-term consequences, including wrecking your credit score or forcing you to cut back on other household expenses including essentials like groceries, utilities, and rent. You may even get into a situation where doctors refuse to treat you if you’re not paying your bills on time, leading you to delay needed health care. “Medical debt really can be the gift that keeps on giving,” Pollitz said, referencing the ongoing negative impacts on people’s finances.

Is my verdict best for you?

On the other hand, HDHPs with health savings accounts attached to them can make good financial sense for “one group,” Pollitz said: people who are “wealthy enough to need a tax-preferred savings mechanism” and can afford to pay whatever health costs may arise. “Partners in law firms usually sign up for them, but the associates and secretaries usually would prefer not to,” she added.

Health savings accounts (HSAs) are a great way to grow wealth over time, said Eric Roberge, a certified financial planner and founder of Beyond Your Hammock, a Boston-based fee-only financial planning firm. “You get to contribute pre-tax dollars, and any growth on the money you invest within the HSA is tax-free as well,” he told MarketWatch. “If you withdraw money and use it on qualified medical expenses, that is also tax-free. It’s the only account that provides this triple tax advantage.” After age 65, you can use your HSA money for anything, not just medical expenses, but you will have to pay taxes on the withdrawals.

A high-deductible health plan with an HSA can work well if you are young, and healthy and don’t incur a lot of medical costs. But if you use medical services frequently or have a lot of high-cost prescriptions, for example, this might not be the best option, because the cost of the high-deductible health plan might not be worth the access to the HSA, Roberge noted. “For folks who can manage their healthcare bills without issue while they’re earning an income from their job and don’t usually have a lot of medical costs each year, opting for the HDHP can not only save you on premiums each year, but it also gives you a chance to grow wealth for the long-term in a highly tax-advantaged way via an HSA,” Roberge said.

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